Abstract
ABSTRACT Objective To identify preoperative clinical characteristics of patients undergoing femtosecond laser-assisted anterior lamellar keratoplasty who failed to achieve optimal postoperative visual outcomes. Methods In this single-center, retrospective case series, patients who underwent femtosecond laser-assisted anterior lamellar keratoplasty between 2013 and 2018 were included if they required graft revision, subsequent corneal procedure, or additional postoperative visits for a femtosecond laser-assisted anterior lamellar keratoplasty-related issue. Visual outcomes assessed included best-corrected visual acuities and postoperative corneal astigmatism. Results Eight eyes of eight patients meeting the above criteria were included. Mean patient age was 64.5 years (range, 21 to 89 years). Mean included preoperative best-corrected visual acuities was one logarithm of the minimum angle of resolution (range, 0.3 logarithm of the minimum angle of resolution to counting fingers). Indications for femtosecond laser-assisted anterior lamellar keratoplasty included anterior stromal scarring due to viral keratitis (two cases), bacterial keratitis (one case), chronic epithelial defect (one case), Avellino dystrophy (one case), trauma (one case), and chronic endothelial failure (two cases). Six patients had history of prior intraocular surgeries including phacoemulsification (four cases), pars plana vitrectomy (one case), endothelial keratoplasty (two cases), and trabeculectomy (one case). Mean included best-corrected visual acuities at most recent follow-up was one logarithm of the minimum angle of resolution (range zero logarithm of the minimum angle of resolution to hand movements) representing improvement or stability in six of eight patients. Visually significant corneal astigmatism was present in four of eight patients. Post-femtosecond laser-assisted anterior lamellar keratoplasty procedures included graft repositioning, arcuate keratotomy, phacoemulsification, and regraft. Conclusion While femtosecond laser-assisted anterior lamellar keratoplasty offers a less-invasive treatment option compared to penetrating keratoplasty, intraoperative and postoperative management can be complex. Femtosecond laser-assisted anterior lamellar keratoplasty in patients with history of prior endothelial keratoplasty or ongoing ocular comorbidities should be pursued with caution.
Highlights
Anterior lamellar keratoplasty (ALK) represents the selective replacement of diseased anterior corneal tissue while preserving the posterior stroma, Descemet membrane and endothelium
Primary indications for the procedure can be summarized as anterior corneal dystrophies, scars resulting from trauma or keratitis, or any other condition that is restricted to the anterior stroma.[1]. The advantages of ALK over penetrating keratoplasty (PK) have been well reported in the literature, including no endothelial rejection, lower risk of “open sky complications”, and a low incidence of anterior synechiae and secondary glaucoma during the postoperative period.[2]
ALK has not gained popularity due to difficulties related to the surgical technique, which often resulted in interface abnormalities at the recipient-donor stromal junction, often culminating in haze, irregular astigmatism and loss of best corrected visual acuity (BCVA).(3) with the advent of phototherapeutic keratectomy (PTK) offering some advantages, like rapid recovery and possibility of repeating the procedure, it was possible to postpone the indication of ALK.[4] being an efficient alternative to treat anterior corneal disorders, it is important to note that PTK is limited by the depth of the lesion, possible induction of hyperopia, irregular astigmatism, and haze formation.[4]
Summary
Anterior lamellar keratoplasty (ALK) represents the selective replacement of diseased anterior corneal tissue while preserving the posterior stroma, Descemet membrane and endothelium. Primary indications for the procedure can be summarized as anterior corneal dystrophies, scars resulting from trauma or keratitis, or any other condition that is restricted to the anterior stroma.[1] The advantages of ALK over penetrating keratoplasty (PK) have been well reported in the literature, including no endothelial rejection, lower risk of “open sky complications”, and a low incidence of anterior synechiae and secondary glaucoma during the postoperative period.[2] Despite these benefits, ALK has not gained popularity due to difficulties related to the surgical technique, which often resulted in interface abnormalities at the recipient-donor stromal junction, often culminating in haze, irregular astigmatism and loss of best corrected visual acuity (BCVA).(3) with the advent of phototherapeutic keratectomy (PTK) offering some advantages, like rapid recovery and possibility of repeating the procedure, it was possible to postpone the indication of ALK.[4] being an efficient alternative to treat anterior corneal disorders, it is important to note that PTK is limited by the depth of the lesion, possible induction of hyperopia, irregular astigmatism, and haze formation.[4]. Subsequent case series of sutureless FALK have reported excellent visual outcomes with minimal postoperative astigmatism.[5,6,7,8,9]
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